Questions and answers about bladder cancer treatment

What types of surgeries are used to treat UBC?

Bladder cancer is usually diagnosed first with an endoscopic procedure, which means we put a small camera through the urethra (the hole we pee through) and into the bladder and take an internal biopsy. This operation is called a transurethral resection of a bladder tumoror TURBT.

For some bladder cancers, this is the only step, meaning patients can be cured with this procedure. But many bladder cancer patients will need many of these surgeries. If their cancer is more advanced, then the patient may choose to have their bladder removed, and this surgery is called a radical cystectomy.

Is the treatment different for non-muscle invasive bladder cancer (NMIBC), when the tumor has not spread to the bladder muscle, and for muscle invasive bladder cancer (MIBC), when it has spread?

Yes, that’s a great point. We really want to know if the cancer is non-muscle invasive versus muscle invasive because the clinical pathways they are completely different. For non-invasive bladder cancer, we can offer treatments to allow the patient to keep their bladder. For muscle invasive bladder cancer, however, many times the bladder unfortunately needs to be removed.

How does intravesical therapy (putting medicine directly into the bladder) work for UBC?

For patients with low-risk, noninvasive bladder cancer, the treatment is TURBT first, followed by surveillance cystoscopies (basically putting a small camera into the bladder in the clinic). It’s a five minute procedure and we do it regularly to confirm that the cancer doesn’t come back.

For non-muscle invasive bladder cancer ranging from more intermediate to high risk, we can offer multiple intravesical (meaning “into the bladder”) treatments. We do this to try to kill any cancer cells that are left in the bladder after that initial TURBT, to prevent the cancer from coming back and to try to prevent it from getting worse. So, if the cancer comes back, these treatments may prevent it from going deeper into the bladder wall.

The most commonly used intravesical treatment is called BCG. BCG is actually a type of immunotherapy, meaning it activates your own immune system to attack the cancer. It is a live, weakened (weakened) version of a bacterium used to make the TB vaccine.

When BCG is placed in the bladder, it basically tricks the bladder into thinking there is an infection. It leads to a massive immune response that ultimately leads to an anti-tumor response. So your own immune system attacks the bladder cancer cells.

BCG is one of the first immunotherapies ever used in medicine and it works very well. Unfortunately, we have a BCG shortage right now in the United States — we just don’t make enough BCG for all bladder cancer patients. So, in recent years, urologists have had to find other ways to treat bladder cancer.

One of the things we started doing is using intravesical chemotherapy. It’s the same chemotherapy we’ve been giving patients through their veins for many, many decades. When given to the bladder, it can help reduce the recurrence and progression of non-muscle invasive bladder cancer.

Can you talk about some of the new developments in UBC therapy?

Unfortunately, sometimes BCG does not work. For patients with non-muscle invasive bladder cancer that does not respond to BCG, we have several other intravesical therapies. It is a very active area of ​​research.

There are many trials underway right now and several drugs that are likely to be approved by the FDA soon. These include new ways of delivering intravesical chemotherapy.

After treatment, is there a high risk of UBC recurrence?

Bladder cancer definitely tends to come back. For low-risk NMIBC, recurrence rates are 30%–40%. For intermediate risk the percentage is about 55%, and for high risk it is 60%-70%.

What are some of the disadvantages and side effects of the various treatment options?

Since bladder cancer tends to come back, having to go back to the surgery a lot is a big deal. There is a risk of repeated exposure to anesthesia and there may be scarring of the bladder because a small piece of the bladder is removed with each surgery. There may also be blood in the urine and infections after surgery.

With intravesical treatments, the vast majority of patients experience symptoms such as urgency, frequency, and pain during urination. Fortunately, we are able to support most patients through all of these side effects so that they can continue with treatments.

What do you wish more women understood about bladder cancer?

Unfortunately, women tend to have worse outcomes than men, and this is partly because they are often not diagnosed until the cancer is advanced. Many women will have blood in their urine that is thought to be caused by a urinary tract infection (UTI). They see providers trying over and over to treat what they think is a UTI until finally someone says, “What if this could be bladder cancer?”

So I wish more people (and providers) knew that blood in the urine is never normal. It could be from a UTI, but after the infection is treated there should be no blood in the urine. If there is — even if it’s a tiny amount — then the patient should definitely see a urologist.